Boots in the Arena. On Combat. Warriors. Invisible Wounds of War

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1 Boots in the Arena the use of EAGALA-model Equine Assisted Psychotherapy in the treatment of Combat Trauma Eva J. Usadi, MA, BCD 2012 PATH, Intl. Conference November 2, 2012 Usadi 2012 On Combat War is an environment that will psychologically debilitate 98 percent of all who participate in it for any length of time. And the 2 percent who are not driven insane by war appear to have already been insane aggressive psychopaths before coming to the battlefield. Lt. Col. Dave Grossman Former U.S. Army Ranger Invisible Wounds of War Post-traumatic stress disorder (PTSD) Traumatic Brain Injury (TBI) Major Depression (MD) Military Sexual Trauma (MST) The signature wounds of the wars in Iraq and Afghanistan Since Oct over 2 million U.S. troops have deployed to OEF/OIF; 793,000 have deployed more than once 300,000 currently suffer from PTSD or MD 320,000 currently suffer from TBI unknown accurate figures of MST Warriors Those who have gone to war. Encompasses all service branches Prolonged exposure to combat no rear Lengthy deployments without enough rest inbetween All-volunteer force = multiple deployments Advanced training = higher firing and kill rates Disproportionately high rate of psychological injuries compared to physical ones Highest ratio of wounded to killed in U.S. history (9:1) Higher survivability but wounds are multiple, with disfiguring injuries to extremities and the face Most casualties since 2005 are from IEDs (40% of all fatalities)

2 Going to war results in: Dysregulation of the nervous system Disruption of the attachment system Violation of the belief system Traumatization occurs when an individual directly experiences a situation perceived as life threatening (or witnesses the death or dismemberment of human beings) experiences feelings of immobility or helplessness to change the outcome (escape) is overwhelmed and unable to use adaptive resources. Post Traumatic Stress Disorder This leads to an inability to process and integrate the experience cognitively, emotionally and somatically. The experience remains fragmented. Post-traumatic stress disorder is a chronic adaptation over time to a real experience. Its symptoms are fueled by the failure to integrate the reality of what happened because it is too overwhelming, which results in a repetitive replaying/reliving of the trauma in images, behaviors, feelings, physiological states, sensations, movement impulses and interpersonal relationships.% % % Trauma and the Body This is expressed as extreme physiological states of hyper and hypo arousal as well as psychological distress trembling, crying, fear, rage, confusion, paralysis which lead to shifts in self perception, usually towards guilt, shame, blame and alienation. When a person is faced with a situation in which there is a threat to life, theirs or others, certain mechanisms in the body prepare for flight or fight, and, when neither of those options are possible freeze or collapse/submission. This is governed by brain chemistry. It is not a choice or an act of will!!

3 Animal Defense System (survival of the individual) Active defenses:% (Sympathetic nervous system) % Flight % Fight Freeze% Passive defenses: (Parasympathetic nervous system)" " " " " % Submit% % % Collapse! Combat warriors return from the battlefield in a heightened state of alertness. This can be expressed as intense anxiety, battle dreams, depression, explosive aggressive behavior, paranoia, jumpiness, an exaggerated startle reflex, inability to fall or stay asleep, suicidal thoughts, as well as guilt, shame, shattered assumptions, lack of trust, feelings of betrayal, problems with interpersonal relationships, and a generalized feeling of unease, or being unsafe.! Role of the Amygdala While warriors may be home, they are still responding as if in combat or fight mode, having been trained not to go into flight or freeze. With PTSD - there are high levels of arousal in subcortical areas such as the brain stem and the limbic system (which interprets the emotional significance of experience).! At the same time there is deactivation of the prefrontal cortex responsible for executive function as well as language. Role of Hippocampus Its function is to record and file memories of an event, putting them in chronological order and perspective before they are consolidated in the frontal cortex. Because hippocampal activity is suppressed during trauma, the raw data remains stored in the amygdala like a sensorimotor photograph. PTSD Simple PTSD is characterized by: Intrusive thoughts and nightmares Avoidance of people, places or reminders Hyper arousal

4 Beyond PTSD However, a majority of traumatized people who seek treatment have a variety of problems not included in PTSD criteria: depression, self-hatred, shame, distrust, dissociation, depersonalization, aggressive behavior against self and others, problems with intimacy, impairment in the capacity to experience pleasure and satisfaction, and the feeling of being permanently damaged. The new criteria expands and enriches the complexity of traumatic experience. PTSD will still be applicable to single event traumas (car accidents), but for the more frequent and more complicated dimension of complex trauma, Complex PTSD or DESNOS (Disorders of Extreme Stress Not Otherwise Specified) may be used. Complex PTSD/DESNOS Criteria Alteration in regulation of affect and impulses Alterations in attention or consciousness Alterations in self-perception Alterations in relationships with others Somatization Alterations in systems of meaning It will be applicable to: those with histories of interpersonal victimization; those who have endured multiple traumatic events; those who have been exposed to grotesque smells, sights and sounds for extended duration:! survivors of childhood neglect and abuse, torture victims and combat warriors Dissociation! The central pathology of PTSD is dissociative experience under conditions of extreme fear, terror and helplessness, when peopleʼs biological and psychological adaptive mechanisms are overwhelmed - certain sensory or emotional (implicit) memories related to the traumatic experience are dissociated only to return as unbidden intense emotional reactions, nightmares, horrifying images, aggressive behavior, physical pain and other bodily states. Leads to the loss of a coherent sense of self. The personality has been split into one part that continues the activities of daily life as if nothing has happened, while the other part holds the implicit memories of the trauma. This is referred to as trauma-related Structural Dissociation of the Personality: where the personality has been divided into the Apparently Normal Personality and the Emotional Personality.

5 Primary military stressors Elements of Combat Trauma Deployment Injury Death Rage Guilt over killing others Grief, guilt over loss of fellow warriors Abuse of alcohol or other substances Trauma-related dissociation Combat-related flashbacks Engaging in high risk activities Misconduct issues Domestic violence Criminality Suicide Untreated combat-related PTSD or MD increases the risk of suicide. In July 2011 the Army recorded its highest rate of suicide on record 32. Active duty suicides have now outpaced deaths on the battlefield and are averaging one per day. On an average day, eighteen veterans of our nationʼs armed forces take their own lives. Judge Reinhart, Ninth Circuit Court of Appeals, May 10, 2011 Group EAP! Group cohesion comprised of 2 factors: 1. All are members of U.S. Military 2. All are inpatients at a psychiatric hospital! Group process:! Each session is the first session no two sessions with the same individuals have ever occurred.

6 Common themes 1. Orientation has been on completion of task (as we defined it); less on process 2. Capacity to use a combination of military discipline and flexibility 3. How is leadership defined? By control or by cooperation? 4. Who (or what) is the alpha male? 5. The contrast between cooperation and competition 6. What is teamwork, and who is on the team (people, horses)? 7. What is safety and how is it determined? Can I have my space and have/maintain attachment to others? (and with whom horses or humans) 8.! Concern for the well-being of the horses has overridden concern for their own well-being 9. Concern for horsesʼ freedom not wanting to force them to comply 10. Feelings of calmness and safety (decrease in dissociation) elicited from close proximity to horses What is Success?? Is it horses doing exactly what the clients wanted them to do or was expected/asked? And by whom -us or the clients? Is it working as a team? Is it learning something new? ( Oh, I canʼt believe the smaller one followed the bigger one without a halter ) Is it completing a goal or discovering a process? ( Can we try it again with no touching? ) Problem-solving and trauma Enhances curiosity which re-engages the frontal lobes; Increases the capacity to be flexible which increases adaptation to the current environment; Facilitates attachment behavior Is it developing better use of metaphors?